Serving the Capital

Gresham Lecture‘Saving Londoner’s Lives’

7th March 2011

SouthCentral

Yorkshire

South East Coastal

Isle of Wight

South West

GreatWestern

NorthEast

East Midlands

West Midlands

NorthWest

East of England

Staffordshire

NEW AMBULANCE TRUST CONFIGURATION

London

About London‘These people, and this city, deserve the very best. The inhabitants of a world-class city should not have to settle for anything less than world-class healthcare’

Lord Ara Darzi

• 620 square miles

• Population of over 7.5 million

• Changing population

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About us• Busiest ambulance service in the UK

• Only pan-London NHS trust

• 1.5 million 999 calls each year

• 1million responses each year

• 750,000 patients taken to hospital

• 5,000 staff and nearly 1,000 vehicles

• Annual increase in demand of 60,000 more 999 calls

• £282m budget

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Our patients

• Critically ill Stroke, trauma, heart attacks, cardiac arrest

• UrgentFalls, non-life threatening illness and injury, long-term conditions

• Non-emergency transportPatients who need support in attendingroutine healthcare appointments

Our VisionA world-class ambulance service for London that meets the needs of the public and all our patients, with staff who are well trained, caring, enthusiastic and proud of the job theydo.

Our priorities

• To deliver a timely ambulance response to 999 callers

• To develop our service so that patients get better and more appropriate care

• To improve patient care without costing more

A timely response to patients

Government-set targets to reach:• 75 per cent of life-threatening (Category A)

calls within eight minutes• 95 per cent of serious but not life-threatening

calls (Category B) within 19 minutes• Category C (not serious or life threatening) –

local agreement

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Types of Calls

Emergency

• Red (Life Threatening)

• Amber (Possibly Life threatening)

• Green (Non-life threatening)

Urgent (Within 3 hours)

Non – Urgent (Pre-booked)

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Mobile data terminal (MDT) destination screen

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Emergency Call Categorisation

• 1.5 million 999 calls received

• Prioritised by Emergency Medical Dispatchers using

• Priority Dispatch Corporation’s Triage System

• Current development of bespoke Computer Aided Dispatch ‘Command Point’

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Dispatch

• Emergency Operations Centre

(& Incident Control room)

• Urgent Operations Centre

• Clinical Telephone Advice

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How do we respond?

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Care Pathways• Advise patients by telephone – hear & treat • Treat and advise patients on scene – see & treat• Onward referral:

Falls team, Community Nurse, GP, Outreach teams• Accident & Emergency Unit – Hospital• Minor Injury Units / Walk in Centre• Specialist Units:

Cardiac, Trauma, Stroke,

• Maternity Unit• Mental Health Unit

Our achievements• Met Category A target for last seven years

• Met financial targets for last seven years

• Improved cardiac arrest survival

• Control services award

• Healthcare People Management Association

recognition of LINC scheme

• London Mayor recognition of Rough Sleepers /

London Buses initiatives

• ASI – 2 recent bravery & 1 Control staff awards

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Improving patient care

Means:

• Better survival rates for our most seriously ill

and injured patients

• More patients’ needs resolved outside

hospital A&E

• Improved patient experience

Cardiac careLAS have been bypassing A&E to convey STEMI patients to specialist cardiac centres since 2006 Journey times have increased by 2mins (average)Improved patient outcomes

– Reduced length of stay– Reduction in occurrence of heart attacks– Reduced risk of stroke & major bleeding– Reduced incidence of death

Associated long term cost saving

Maximising Early DiagnosisFrom Plaque Rupture to Primary PCI

Early symptom recognition

Paramedic ECG

Decision for direct transfer

Confirmation in cath lab

Chest Pain call

Primary PCI

1998-1999

2001-2002

2002-2003

2003-2004

2004-2005

2005-2006

2006-2007

2007-2008

2008 -2009

2009-2010

0

5

10

15

20

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London Ambulance Service NHS Trust Cardiac Arrest Survival Rates

Overall Survival RateUtstein Survival Rate

Perc

ent

Trauma Centres• Local Trauma units cluster with MAJOR Trauma centres

• LAS take seriously injured patients direct to Major centres – improving patient outcomes

RTC 21638%

Stab or Shot 15327%

Other 427%

Assault 285%

Unknown 142%

Fall 10919%

Mechanism of serious injury5th April - 1st June 2010

Face Arms & Speech Test

London’s Hyper Acute Stroke Centres

Priority call 09:17 to HASU arrives 09:28

CT scan shows ischemic stroke - thrombolysis and hyperacute stroke care required

“Within an hour, his paralysis corrected. Previously someone with a stroke as serious as this could have expected to spend the rest of their life in a nursing home, if they survived”

( Dr Khan, Stroke Consultant) Now discharged and back to his

hobby of playing the accordion

Stroke Case Study

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Current challenges• Meeting response time targets• Providing more care outside hospital; up-skilling

our staff• Replacing our 999 call-taking system• Being ready for the Olympic and Paralympic

Games• 6% year on year increase in demand

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By how much is ambulance demand rising?

• The number of calls handled by ambulance services in England is increasing by 6.5% each year on average, which is equal to approximately 300,000 extra calls each year.

• At an average cost of £200 per call, this represents an additional cost of £60 million pounds each year.

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Top ten illness codes• ‘Other medical conditions’• Abdominal pains• Pain –other• Generally unwell• No injury or illness• Head injury (minor)• Difficulty in breathing• Minor cuts & bruising• Alcohol related• Possible fracture

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Factors Affecting Demand• Seasonal factors• Social/attitude change • Long term conditions• Aging population• Frequent callers• Deprivation • Alcohol• Changes to patient care

42What contribution has alcohol-related behaviour made to ambulance demand?

• Alcohol-related incidents are increasing in London and nearly 1 in 20 London ambulance incidents are alcohol related.

• Binge drinking behaviour and the increasing affordability of alcohol may also be reflected in other ambulance activity trends, such as the significant increase in the number of calls from 20-29 year olds and the changes in the day and time of calls to the ambulance service.

• From 2000/01 to 2007/08 there has been a trend for more Trauma and Falls ambulance incidents to occur on the weekend evenings.

0

100

200

300

400

500

600

700

800

900

0 to 9 10 to19

20 to29

30 to39

40 to49

50 to59

60 to69

70 to79

80 to89

90+

Age group

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bu

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ce

in

cid

en

ts p

er

10

00

he

ad

of

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lati

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Number of ambulance incidents per 1000 head of population, by age group, London Ambulance Service, 2007

Estimate of 2007 ambulance incidents, based on 2000 ambulance utilisation rates and 2007 age structure, London Ambulance Service

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90+

Age group

Nu

mb

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f am

bu

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ents

2000 Actuals 2007 Actuals 2007 Estimates

ONS Mid-year population estimates;London Ambulance Service data

“Many of patients transported by

ambulance to A&E are discharged

from A&E without the need for follow-up”

“A small number of patients

account for a

disproportionately large

portion of ambulance activity”

“Changes in people’s attitudes and

expectations may mean they are using

999 to get rapid and convenient access

to health services”

“Demand for ambulance services is

rising by over 6% each year”

• What is the ambulance

equivalent of a smoke alarm ?

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5%

6%

6%

14%

18%

32%

Q What do you think is the single most important role of the Ambulance Service?

Base: All respondents (1,010); Fieldwork dates: 19th June – 2nd July 2006

Top 6 answers

Speed of response is most important role

Responding quickly

Responding to a major emergency (e.g. a train crash)

Getting to emergency patients

Transporting patients to hospital(No mention of emergency)Transporting emergency patients

Treating injuries

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London After Dark• Increase in alcohol related incidents• Increase in RTCs, slips trips and falls• Increase in ‘no patient found’ • Increase in staff assaults and abuse • Difficult demand peak between 23.00 and 03.00• Difficulty in locating address / callers• Rough sleepers project

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A service that responds appropriately to all our patients

A service that looks, feels and behaves, and delivers differently

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